The Mental Costs of Being a Refugee in America

Getting psychological help from an unfamiliar healthcare system comes with serious challenges.

When Ahmed Hassan decided to major in psychology at Southwest Minnesota State University, his Somali-born community assumed he was training to be a psychic. Not an unexpected reaction, given the popularity of psychic hotlines in the early 2000s—and the lack of anything equivalent to psychotherapy in Somalia.

Hassan, of course, had no interest in the likes of Miss "Call Me Now!" Cleo. He'd gotten an A in his intro to Psychology course, and wanted to learn more.

But there's no word for mental illness in Somali. "You are either sane or insane," says Muna Mohamed, a Somali-born case manager at a mental health support clinic in Minneapolis. "There is nothing in between."

Minnesota is currently piloting mental health screening for refugees, and this is part of an upward trend: About half of states now offer some sort of mental health screening for refugees or new immigrants, up from about four in 2010. This includes California, where most of the 12,000 Syrian refugees in the US have landed. "One reason for doing the screening is that about a third of refugees will have a diagnosable condition such as PTSD or depression, and 50 percent will have experienced torture—themselves or an immediate family member," says Patricia Shannon, associate professor in the School of Social Work at the University of Minnesota. "But not all will have a diagnosable condition. Many of those who don't are still vulnerable to mental health issues, however: Many were exposed to trauma in the course of being a refugee, fleeing through jungles or other unsafe conditions. We need to get them help sooner rather than later so they can get to a healthy resettlement."

But successful treatment is complex, requiring a multi-pronged approach to effect change. Immigrant hubs across the country face a steep learning curve of setting best practices for newly-arrived refugees who do not share the Western concept of mental health. That means everything from systemic reorganization (starting with the screenings in that first medical exam), to overcoming language barriers and confidentiality issues with unregulated interpreters, to basic Western psychoeducation. None of those things can happen without people who can bridge cultural gaps, who understand that "mental illness" translates to "crazy" in another language. Hassan is one of a small but growing number of Somali-born psychotherapists who connect the two cultures.

During a time when Somalis were fleeing the country's civil war, fighting between clans, and a famine, Hassan won a lottery for a Diversity Immigrant Visa that granted him entry to the US. Even now, Hassan's deep brown eyes sparkle when talking about it: "I don't get excited easily, but that's one moment I was just so excited I didn't even feel my body," he says. "I was so excited, I was jumping, screaming, doing crazy things. Even when I graduated from college, I didn't feel that way."

When his plane landed in Virginia in 2002, he had a backpack and $20 in his pocket. He and the Somali family he stayed with would go to a mall and a bowling alley and watch the crowds, unaccustomed to seeing people who looked different from them: Asians, whites, African-Americans. Within a few months, Hassan, eager to pursue a college degree, decided to move to Marshall, Minn., population 13,680, to attend Southwest Minnesota State University. Marshall was home to a community of Somalis ever since the town's turkey plant started hiring Somali workers in 1992. Of the approximately 84,000 Somali refugees in the US, about 40 percent live in Minnesota because of the state's active voluntary agencies that work with the State Department to resettle refugees.

Before majoring in psychology, Hassan's experience with mental health was typical of any kid growing up in Somalia. When he was 15, he remembers being with a friend at a mosque when a nearby woman fainted. A bystander told them the woman was experiencing jhin, or being possessed, and asked them to read Quranic verses.

"My friend and I read random verses, and after an hour she woke up," Hassan says. "At the time, we attributed everything to the verses, because we'd read the Quran and she felt better and woke up."

After 30 minutes of therapy the client looked at me and said, 'Why is she asking so many questions?'

Studying psych in the US, he enjoyed learning about theories of human behavior. But gaps between cultures persisted: It wasn't until graduate school that Hassan fully understood talk therapy. "No one did the ABCs of what it was," he says. He learned while working as an interpreter on an assignment to take a Somali woman who was having trouble sleeping, presumably due to PTSD, to a psychiatrist. When the doctor referred her to a healthcare provider next door, Hassan helped the woman set up an appointment, assuming the provider would take X-rays or blood samples.

"But we went the next day, and the [provider] kept asking question after question," Hassan remembers. "After 30 minutes the client looked at me and said, 'Why is she asking so many questions?' I said, 'I have no idea.' Finally she handed her a slip of paper and said, 'Come back next time.'"

Hassan and the client assumed the paper was a prescription, but the provider explained that she didn't dispense medication; the paper was to be given to the receptionist to set up another appointment.

"The client looked at me and said, 'I will never go back to that woman,' and I said, 'Well, I don't blame you. After all that, all she can give you is this piece of paper?'"

The theory of talk therapy struck Hassan as completely bizarre. Months later, he ran into the client. He asked the woman if she'd gone back.

"She said, 'Yes. I like her now.' I think she went back because she felt the [therapist] cared about her."

It's a concept that requires experience to appreciate, says Hassan, who says talk therapy is what he now enjoys most in his work.

When care providers don't completely comprehend the chasm between cultures, patients are often misdiagnosed—or go undiagnosed.

Hassan witnessed this while working as an interpreter: A psychologist started asking a patient if she was seeing people who weren't there. The woman, who believed in Sufism, or Islamic mysticism, told him she saw and talked to dead people all the time, even threw food to them (a common practice to give the spirits something to eat). Alarmed, the psychologist decided the woman needed to be hospitalized for hallucination. "Everyone who knew her knew she was just normal," Hassan says. After much struggle and explanation, the woman avoided being hospitalized, but the experience frightened Hassan, knowing that many in the Somali community are scared about being institutionalized against their will.

Often vague physical symptoms such as headaches or stomachaches was undiagnosed mental illness.

That was an extreme case, he says; more common are situations in which patients describe mental illness in terms of headaches, stomachaches and heaviness in their legs—and as a result get prescribed inappropriate medication. In 2004, Mayo Clinic researchers analyzed hospital records of Somali immigrants to Minnesota, noticing references to "Sick Somali Syndrome." Often, the researchers concluded, the culprit of the mystery symptoms—vague physical symptoms such as headaches or stomachaches that couldn't be traced to a root cause —was undiagnosed mental illness. Mental illnesses often manifest as physical headaches and stomachaches when left untreated.

"When mental health and stress are not addressed in refugee populations, there can be long-term adverse health consequences such as diabetes, hypertension, chronic pain, and other chronic health conditions," says Shannon. "We know now that physical health and mental health are connected."

After graduation, Hassan founded Summit Guidance in 2011, billing itself as a culturally competent mental health clinic. Almost every time a new client walks in the door of the clinic, located in a nondescript office building in St. Paul, Hassan sits down with them for a free consultation in which he answers their big questions: 'if you diagnose me will it prevent me from finding a job or ruin my son's future?' … or 'if i tell you this and this, will immigration arrest me?'" He explains exactly what will happen in psychotherapy [i.e., lots of talking, no drugs, no X-rays.] He walks them through HIPAA forms, explaining the concepts of privacy and confidentiality, which don't exist in the same way in many countries, especially those with rogue governments. He points out the numbers listed on the form they can call if they feel that he violates the agreement.

Still, he finds that clients ask the same questions he'd initially asked after his introduction to talk therapy: "Well, what good will you do if we just sit here and talk?" So Summit Guidance also offers services to help people find housing and employment. The combination, he says, works better than psychotherapy alone.

"If a client comes in and says, 'Oh, I am depressed and sad because I don't have good housing,' then once they have housing and are still depressed, they may be willing to explore what's going on," he says.

Research has been able to identify some best practices (Shannon points to a study that found that 76 percent of patients kept an appointment when a doctor personally introduced them to the therapist, vs. 44 percent of patients who kept appointments when they were not introduced), but in general, "Mental health is not a cookie-cutter system," says Ellen Frerich, a refugee health nurse consultant for the Minnesota Department of Health. "One person might need a psychoeducation group, whereas another might need in-patient care."

Every single client requires a unique treatment plan, says Andrea Northwood, director of client services at The Center for Victims of Torture. "There are no shortcuts," she says. "So we need to work with each individual's family, tribe, social class. I have some Somali clients who ask me to explain the neuroscience of trauma, whereas for others, simple psychoeducation [educating patients about their mental health conditions] offered by an imam could be enough."

While some of those challenges will always be inherent in treating immigrants with mental health issues, other challenges are surmountable. Take interpreting. "Interpreters are regular folks with not enough training about ethics and confidentiality," says Hassan, who knows from personal experience.

Because medical interpreters aren't regulated in most states, "anyone can put up a shingle," says Northwood. "Interpreting is a very challenging profession. There are codes of ethics; that's what we train people in."

For $50, anyone can add their name to a registered list in Minnesota, ethics training or not. Some organizations and agencies provide training, and individuals can apply for accreditation through two new national organizations, but the need far surpasses the number of properly trained interpreters.

"Talking to an older gentleman, I asked about his experience with a previous therapist," Hassan says. "The man said, 'after a while, I thought the interpreter wasn't telling the therapist what I was saying, so the whole thing didn't work and that's why I left him."

Conflicts of interest arise: A patient is paired with an interpreter who came from a warring tribe in their home country, or someone who lives in their building.

According to medical ethics, interpreters are supposed to translate everything a medical provider says and everything a client says. But untrained interpreters may pick and choose how much of a conversation to translate from either end, making experiences such as the older gentleman's common.

Conflicts of interest often arise as well: a patient is paired with an interpreter who came from a warring tribe in their home country, or someone who lives in their building. And some interpreters are fluent in one language but not entirely in the other, so can't make perfect translations.

Minnesota is currently considering a bill for a registry recommended by the Minnesota Department of Health similar to Oregon's, one of the few states that regulates interpreters.

After the election, many Somali Americans in Minnesota are on edge. Without citing any evidence, Donald Trump suggested at a pre-election rally that Somali immigrants to Minnesota hadn't been fully vetted, and vowed that his administration would "not admit any refugees without the support of the local communities where they are being placed." Also in November, nine Minnesota men were sentenced to decades in prison after being found guilty of trying to join ISIS.

Hassan discusses such current events in sessions he holds at mosques to talk to young people directly about mental illness, in addition to questions about substances, anxiety, depression and explaining how therapists can help.

Today's children of immigrants may face new issues, Hassan says, pointing to an African proverb: A mule that eats grass with a horse thinks of himself as a horse. He's been exploring African proverbs recently, with the idea that ancient nomads predated Western thinkers and that many of the messages relate to mental health and "get to the core where everyone can get access and use it."

The mule proverb "talks about the young people who are going to school here with this culture, but that culture doesn't think they're quite American and their own family doesn't think they're quite Somali," he explains.

"But if the culture is rejecting them and parents are not letting them assimilate, they end up with an identity crisis. Then often they're using substances to deal with their confusion."

Hassan is now well-known as a Somali-speaking psychotherapist in Minnesota, and no longer gets mistaken for a psychic. But what he talks about more enthusiastically is his growing number of Somali colleagues.

"Younger people are kind of looking at us and saying, 'Oh, I want to do something similar," he says.